The current controversy regarding the right to bill for noncontracted services rendered, also known as balance billing, pits two segments of the medical profession against one another. In one corner are large organized groups with capitation contracts whose compensation is adversely affected by out-of-plan patient care. In the other corner are physicians who render care on an urgent or emergent basis and who are not in the patient's network.
The current controversy regarding the right to bill for noncontracted services rendered, also known as balance billing, pits two segments of the medical profession against one another. In one corner are large organized groups with capitation contracts whose compensation is adversely affected by out-of-plan patient care. In the other corner are physicians who render care on an urgent or emergent basis and who are not in the patient's network.
HMOs are the central focus of this conflict. Insurance company executives think all physicians ought to be willing to accept HMOs' discounted reimbursement, even if the doctors are not contracted with the HMOs. If noncontracted doctors did this, then essentially the insurance companies would be setting all fees for all physicians.
Mandated cessation of balance billing would be the final nail in the coffin killing private practice and physician independence. Doctors would be little more than employees of the health plans, duty bound to accept whatever is offered for their services no matter the urgency, complexity or time-intensity.
From the patient point of view, the argument against balance billing is appealing. Why should I have to pay over and above what my health plan allows because I happen to become ill or injured away from where my plan's physicians practice?
As compelling as the patient argument against balance billing sounds, it will lead only to more physicians avoiding ER coverage responsibilities and not accepting out-of-plan patients because of low compensation and other difficulties.
Over the past 20 years, physicians have lost a great deal of independence regarding timeliness and quality of care, deferring to insurance company reviewers, whose main purpose seems to be to delay authorization and payment. Physicians are legally barred from acting in concert to oppose this by the Maricopa decision of many years ago.
Boutique medicine is one partial answer to physicians' loss of ability to do what we feel is best for the patient. However, this works for only a small segment of society. What's at stake is the availability of physicians for appropriate care to the general population. If we physicians are employees of the insurance companies or the government, we will be doomed to a two-tier system of healthcare in which timely service is available only to the wealthy.